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In this research project I rely upon theories that grapple with identity formation, visual expression and social locations that are relative, temporal and contextual. This chapter also investigates the concepts of selfhood, autonomy and agency that are central to my project, as they have been developed by selective writers in the fields of philosophy, feminist legal theory, social theory, anthropology and applied ethics. First, I begin with a brief discussion of

intersectionality theory as an approach to coalesce trans racialized youth’s multiple identities, experiences and responses to health care inequities. I then connect intersectionality to the related theory of structural vulnerability as a way to understand how institutions and systems relegate trans racialized youth to subordinate positions. In the second section, I lay out the conceptual groundwork for my argument about how to understand the decision-making experiences of trans racialized youth by contrasting the ideas of autonomy and agency. I specifically focus on a relational theory of autonomy. I consider how scholarship on relational autonomy accounts for selfhood, collective identity, race/ethnicity and gender that are situated in sociopolitical

dynamics and also embodied. In the third section, I lay out Muñoz’s disidentification, a theory for the artistic practices, products and interpretations by marginalized queers in response to lack of cultural representation or misrepresentation.133 Disidentification will be used to analyze the photographic essays created by trans racialized youth in Chapter 5. Lastly, in the fourth section I describe Transgender Theory, developed by Nagoshi and Brzuzy in 2010.134 This theory builds

133 _{Jose Esteban Muñoz, Disidentifications: Queers of Colour and the Performance of Politics, Cultural Studies of} the Americas (Minneapolis: University of Minnesota Press, 1999).

134 _{Julie L Nagoshi & Stephann/ie Brzuzy, “Transgender Theory: Embodying Research and Practice” (2010) 25:4} Affia 431.

on and challenges feminist and queer theories of gender, integrating as key features:

embodiment, socially-constructed gender, essentialism, and intersectional political solidarity. I use this gender theory to guide my qualitative research methods as required by Singh in her checklist for researchers which I explain in detail in Chapter 3.

Intersectionality

Patricia Collins, articulated the concept of intersectionality to mean “particular forms of intersecting oppressions, for example, intersections of race and gender, or of sexuality and nation”.135 _{An intersectional framework can result in a more accurate analysis of how social}

factors determine health136 _{because it accounts for simultaneous as well as interacting}

experiences of oppression.137 Using an intersectional approach means that experiences linked to social identities can be understood as more than simply cumulative experiences.138 While an “add-on” view of multiple oppressions assumes that people with multiple marginalized group

135 _{P. H. Collins (2000). Black feminist thought: Knowledge, consciousness, and the politics}

of empowerment. New York: Routledge. Collins refined the concept coined by critical legal theorist Kimberlé Crenshaw in Crenshaw, K. (1991). Mapping the margins: Intersectionality, identity politics, and

violence against women of color. Stanford Law Review, 43(6), 1241-1241. Black and lesbian of colour feminists and writers have theorized their experience of multiple identities and therefore multiple oppressions since the 1970s. Cherrie Moraga & Gloria Anzaldua, This bridge called my back: writings by radical women of color (Watertown, MA: Persephone Press, 1981); Audre Lorde & Black Women Writers - York University, Sister outsider: essays and speeches, Black women writers (Trumansburg, NY: Crossing Press, 1984); Gloria T Hull, Patricia Bell Scott & Barbara Smith, All the women are white, all the blacks are men, but some of us are brave: black women’s studies (Old Westbury, NY: The Feminist Press, 1982).

136 _{The concept of social determinants of health was developed by the World Health Organization, see Commission} on Social Determinants of Health, Closing the Gap in a Generation: Health Equity through action on the social determinants of Health, Final Report: Executive Summary (Geneva: World Health Organization, 2008). 137 _{L. Bowleg (2012). The Problem with the Phrase Women and Minorities:}

Intersectionality-an Important Theoretical Framework for Public Health. American Journal of Public Health, 102(7), 1267–73.

138 _{D. King (1990). Multiple jeopardy, multiple consciousnesses: The context of a black}

feminist ideology, in M. Malson, E. Mudimbe-Boyi, J. O’Barr, & M. Wyer (Eds.), Black women in America: Social science perspectives, (pp. 265-295). Chicago, IL: University of Chicago Press.

identities experience oppression as a sum of the distinct discriminatory experiences, intersectionality theory instead says that they experience oppression uniquely.139

Intersectionality as a hermeneutic has implications for methodology. As a theoretical framework it can lift methodology out of the pitfalls of victimhood and oversimplified identity politics.140 For example, rather than only comparing experiences of oppression or discrimination, intersectionality requires the consideration of privilege and fortunate circumstances.141

Furthermore, intersectionality recognizes the qualitative differences between identities.142 To illustrate, a person can become disabled by an accident or by aging, similarly a person’s class might change through professional mobility, whereas their race and ethnicity will not change. Intersectional research design then must attend to the fact that participants may not be able to tell which of their characteristics is driving discrimination.143 Results of a national U.S. survey on transphobia showed that white trans people experienced higher rates of transphobia than black trans people in some healthcare contexts.144 _{The Trans Legal Needs survey is a local example of} this phenomenon, where trans participants of colour expressed difficulty in separating out racism and transphobia when answering questions about experiences of transphobic discrimination.145

139 _{Lisa Bowleg, “When Black + Lesbian + Woman ≠ Black Lesbian Woman: The Methodological Challenges of} Qualitative and Quantitative Intersectionality Research” (2008) 59:5–6 Sex Roles 312; Feminists like Julia Serano and Moyo Bailey have forged terms like “transmisogyny” and “misogynoir” in attempts to precisely characterize intersectional experiences of oppression. Julia Serano, Whipping Girl: A Transsexual Woman on Sexism and the Scapegoating of Femininity (Seal Press, 2009) at 15; Marie Solis, “Meet Moya Bailey, the black woman who created the term ‘misogynoir’”, (30 August 2016), online: Mic <https://mic.com/articles/152965/meet-moya-bailey- the-black-woman-who-created-the-term-misogynoir>.

140 _{Umut Erel et al, “On the Depoliticisation of Intersectionality Talk: Conceptualising Multiple Oppressions in} Critical Sexuality Studies” in Theor Intersect Sex, Genders and Sexualities in the Social Sciences (Palgrave Macmillan, London, 2010) 56 at 281–282.

141 _Ibid.

142 _{S. A. Shields, (2008). Gender: An Intersectionality Perspective. Sex Roles, 59(5-6), 301–311.} 143 _{Shanna K Kattari et al, supra note 68 at 75.}

144 _Ibid.

Although it is not practical or possible to consider an exhaustive list of intersecting identities, if research questions are designed and disseminated inclusively enough, all identity dimensions can be accessed, acknowledged and analyzed throughout the project.146

Lastly, intersectionality is aware of the nuanced and shifting multiple identities of people, which is critical for working with trans racialized youth who might transition more than once and in more than one context (medical, social, legal).147 _{In conclusion, the theory of intersectionality} captures how all of the dimensions of one’s identity shape one’s understanding and experience of a situation and affect the nature of the decisions and actions that follow. The conditions for autonomous behaviour are deeply connected to our multi-dimensional identities. We will see next how institutional, interpersonal and discursive structures produce vulnerability for trans racialized youth that affect their practice of autonomy.

Structural Vulnerability

Structural vulnerability is a concept derived from Galtung’s theory of “structural violence”.148

It describes a subordinated position in a hierarchical society caused by being a member of more than one oppressed group, where multiple networks of power permeate social, personal,

environmental, and legal realms causing stress and shortening one’s lifespan.149 According to medical anthropologists Quesada et al., cultural and social sources of stress include “(1) social

146 _{Bowleg 2012, supra note 138.}

147 _{Ibid; see also recent work by Julia Temple Newhook et al, “A critical commentary on follow-up studies and}

‘desistance’ theories about transgender and gender-nonconforming children” (2018) 19:2 International Journal of Transgenderism 212 at 213, 216, 219-220.

148 _{Galtung J. (1969) Violence, peace and peace research Journal of peace research 6(3):167-191, at 183.}

149 _{James Quesada et al, “Structural Vulnerability and Health: Latino Migrant Laborers in the United States” (2011)} 30:4 Med Anthropol 339 at 342, 351.

hierarchies scaffolded by categories bestowing entitlement; (2) historically distinctive discourses of normativity and ethics; and (3) the intersection of individual medical pathology and biography with social exclusion.150 I will relate each of Quesada’s points to the structural vulnerability of trans racialized youth. Firstly, categories like gender/sex, and race exist in law and medicine and buttress sociopolitical hierarchies of capitalism, ableism and patriarchy by determining access to housing, education, and health care. Secondly, professional norms for dealing with trans

racialized youth build on epistemologies of transsexuality and transness established discursively over centuries through medicine and law. Thirdly, Quesada et al. also include as structural vulnerabilities, the way a person’s individual appearance, affect, voice, medical conditions and cognitive abilities are “read”, i.e. by professionals within institutions and public spaces.151 _This

iterative and socially constructed element of an identity is extremely relevant for trans racialized youth as they move through the world, being assessed by cisgender health care providers who ultimately decide whether they can access the treatments they want. How the act of “reading”152 or ascribing race/ethnicity and gender categories to others can contribute to social exclusion and divided selfhood, is explored in greater detail in the following section on relational selfhood.

Incorporating intersectionality theory, Quesada et al. explain that “Experiences of

vulnerability, however, are only partially shared across populations because they are shaped unevenly by specific status attributes (i.e., gender, age, ethnicity, etc.), conditions (i.e., legal

150 _{For this analysis at 341-42 Quesada et al. rely on Pierre Bourdieu, Pascalian meditations (Stanford: Stanford} University Press, 2000); and Michel Foucault “The ethics of the concern for self as a practice of freedom”, in Michel Foucault, Paul Rabinow & Robert Hurley, Ethics: subjectivity and truth, Dits et écrits English Selections; v 1 (New York: New Press, 1997); João Guilherme Biehl, Vita: life in a zone of social abandonment (Berkeley: University of California Press, 2005).

151 _{Quesada et al, supra note 150 at 351.}

152 _{Serano describes the practice of “reading” or “gendering” and its impact on her sense of self in Serano, supra} note 140 at 164.

status, economic and living conditions, etc.), and individual serendipity.”153 _{For example, some} Black or Indigenous people may have grown up in foster care, and experienced different types of violence or racism than counterparts who grew up with their families of origin. On the other hand, someone who develops secondary sex characteristics that are closer to the gender

presentation they desire will have less trouble being “read” by others as the gender they feel. A

critical part of the intersectional approach is recognizing the heterogeneity of individual biographies of social exclusion and vulnerability within identity groups.

Oppression is often internalized by multiply and historically oppressed people over generations.154 For example, they may understand themselves, or in other words, form their subjectivity, in relation to oppressive discourses that valorize productivity, heterosexuality, ability and whiteness. Their own narratives may reflect a sense of deficit or failure. And as a result, structurally vulnerable people often behave as though they deserve the ill health they experience especially where the discourse of neoliberalism has told members of society that they are responsible for all of their outcomes and that poverty or ill health is a result of their own deficiencies as entrepreneurs.155 Structural vulnerability then, situates the pressures felt by people addressing health and health care that may influence their choices. Understanding their health care decision making process requires us to deconstruct the notions of choice and voluntariness that are central to the now legislated practice of informed consent. To do this, in the next section I will first unpack the concept of “autonomy” or self-governance through the

153 _{Quesada supra note 150 at 346.} 154 _{Ibid at 352.}

155 _{Jennifer M Denbow, Governed through Choice: Autonomy, Technology, and the Politics of Reproduction (New} York: NYU Press, 2015) at 104–105; Peter Miller & Nikolas S Rose, Governing the present: administering economic, social and personal life (Cambridge, UK: Polity, 2008) at 92.

lens of relational theory. I will then apply it to the health care context where autonomy is presented by Ontario’s legislators and health care professionals as an animating principle.

Accounting for Autonomy

The principle of autonomy continues to infuse the field of bioethics currently affirmed by Canadian statutes, jurisprudence and scholarship. Still, traditional theories of personal and political autonomy have been widely criticized by feminists resulting in the reshaping of autonomy by some who wish to retain it as a value.156 I map the development of a relational theory of autonomy arising from specific conceptions of the self, the collective and augment academic feminist relational theory with grounded theory by women of colour scholar activists from reproductive justice movements. This discussion includes a consideration of the

relationship between reproductive autonomy and broader notions of autonomy for health care decision making, as well as Black women’s and women of colour’s critiques of reproductive autonomy in favour of reproductive justice. I use the reproductive justice movement as an example to demonstrate that in order to achieve autonomy producing conditions for structurally vulnerable people, we have to place equity and justice at the centre of autonomy struggles. In this way I consider autonomy as a practice that is socially and politically enabled, not a final

destination for those with privilege.

156 _{Jennifer Nedelsky, “Reconceiving Autonomy: Sources, Thoughts and Possibilities” (1989) 1:1 Yale J Law Fem 7} at 8 [Nedelsky 1998]; it is worth noting that Roberts does not totally discard libertarian autonomy because she sees it as beneficial for Black women and women of colour in two ways: it emphasizes self-definition and it can offer protection from state incursions on bodily integrity. Both could be useful strategic avenues. Dorothy E Roberts, Killing the Black Body: Race, Reproduction, and the meaning of Liberty, 1st ed. ed, Black women writers (New York: Pantheon Books, 1997) at 297; Susan Sherwin, The politics of women’s health: exploring agency and autonomy (1998) at 32 [Sherwin 1998].

Traditional versions of autonomy are synonymous with either self-governance or liberty.157 Roberts ascribes the subsequent North American libertarian reorientation of autonomy to Immanuel Kant’s moral philosophy.158 _{For Kant, rational independent agents still only follow}

laws they have created themselves or that they judge to be acceptable, but preventing state intervention is the central theme.159 Liberty as a value and a practice did not guarantee equality for racialized and enslaved peoples. In this framework, rights act as negative liberty, in other words, freedom from undue democratic state limitations on their actions or property. The essential feature of personhood, in Kantian reasoning, was to be a rational, independent individual. In fact, if libertarian autonomy was elevated as an ideal, it served to valorize the choices of the most privileged who were white men with private property who constituted the government.160

I will be examining a different conceptualization of autonomy derived from relational theory. The liberal atomistic person, in theory, derives their sense of self purely from their individual experiences and interests and ignorant to benefits or liabilities caused by their membership in

157 _{Autonomy has its Western origin in the works of Jean Jacques Rousseau who used autonomy as the glue for the} self-governing social contract made between man and society in which man sacrificed some of his individual liberty to become a member of a nation. Rousseau attempted to move from the goal of liberty as “freedom from

interference” to political cohesion through the social concept of autonomy. Rousseau’s autonomy involved submitting to laws of one’s own creation in Jean-Jacques Rousseau, The social contract, Great ideas (New York: Penguin Books, 2006); Frederick Neuhoser, “Jean-Jacques Rousseau and the Origins of Autonomy” (2011) 54:5 Interdiscip J Philos 478.

158 _{Roberts cites Kant as foundational in the American Constitution, ensuring that white men of property could build} a nation with minimal state intrusion on their ability to act since they themselves devised Constitutional law in Roberts, supra note 157 at 295.

159 _{Immanuel Kant laid out this philosophy in The Groundwork of the Metaphysics of Morals. Kant was influenced} by Jean Jacques Rousseau who focused less on morals and more on political formations, less on liberty as freedom and more on social autonomy. Immanuel Kant, The moral law: groundwork of the metaphysics of morals, translated by H. J. Paton (London: Routledge, 1997).

social groups.161 _{The starting point for relational theory, on the other hand, is that humans are} constituted by their relationships. This includes relationships to oneself, and to family, friends, society, institutions and nation. Relationships may foster or undermine autonomy. Because of its implications for rights and justice, I use relational theory as a lens through which to argue that gaps in the Health Care Consent Act and related policies block the formation and growth of relationships of autonomy for trans racialized youth. Nedelsky, who theorized a relational version of autonomy and later popularized the concept of rights as relationships, considers what positive rights would mean for autonomy.162 _{Positive rights require governments and private} actors to do more than protect people from one another.163 For example if positive rights included the right to housing or the right to live in one’s felt gender, governments would need to support

conditions that actualized those rights. This would require nourishing relations conducive to practices of autonomy. To determine what those conditions are, let’s look at what Nedelsky considers the ingredients for autonomy: self-determination, peace, security from oppression and power, confidence, dignity, efficacy, and respect.164 It is easy to see how structurally vulnerable people would struggle to practice autonomy given that they experience daily attacks on their peace, security and confidence to say the least. The next section will focus on the formation of selfhood as a critical ingredient of autonomy.

The Relational Self

161 _{Stephanie J Kapusta, “Trans Authenticity and the ‘Feminist Legacy’ of Relationality” in Robert Scott Stewart,} ed, Talk Sex Multidiscip Discuss (Sydney, NS: Cape Breton University Press, 2013) 146; Nedelsky 1989, supra note 157 at 8.

162 _{Nedelsky 1989, supra note 157.}

163 _{Jennifer Nedelsky, “Reconceiving rights as relationship” (1993) 1:1 Rev Const Stud 1 at 14 [Nedelsky 1933].} 164 _{Nedelsky 1989, supra note 157 at 11.}

To govern oneself, one must be in a position to act competently in congruence with values, desires, goals and interests that are one’s own.165 _{Therefore an awareness of one’s self is crucial}

to the exercise of autonomy.166 _{A relational view of autonomy sees a person define their selfhood} partly through the relationships they have with family members, professionals, institutions, cultural and political collectives and even non-human beings and also through their own internal essence.167 Relationships that foster autonomy require equity, information exchange and personal growth. And yet, many of our relationships are embedded in the systems of oppression that make us structurally vulnerable. Therefore, relationships can also impede autonomy.

Selfhood also means being in touch with other building blocks of the self, such as by

developing an awareness of one’s cultural history, and group cultural practices. These augment and sometimes conflict with one’s own individual values, needs, interests and goals.168 Yet another way that the self is constituted is through social interactions where central traits such as gender and race which, as Oshana argues, are mostly socially ascribed to us by others.169 Simply put, we are “read” by other people and this is how we are racialized or gendered. Oshana

describes being alienated from a Blackness that is ascribed to her by others, and connects the experience to her biracial self-conception and her professional identity as an academic.170

165 _{Joel Anderson & John Christman, “Introduction” in John Christman & Joel Anderson, eds, Autonomy and the}

Challenges to Liberalism: New Essays (Cambridge, UK: Cambridge University Press, 2005) 1 at 3.